Congenital syphilis (CS) remains a major source of perinatal and infant mortality in sub-Saharan Africa and in high risk groups in the U.S. A major reason for the continued occurrence of CS is the inability of primary health care (PHC) services to provide a sustainable screening and treatment program. Dependence on centralized system of screening has been identified as the critical obstacle in the performance of the screening program. Moreover, a number of reports from the U.S. have drawn attention to the fact that current recommendations of prenatal treatment of gestational syphilis (GS) for prevention of CS may be inadequate. As part of the national effort to improve the effectiveness of maternal and child health programs, the Ministry of Health of Ethiopia introduced a program of rapid plasma reagin "teardrop" (RPR-TD) test for screening and treatment of GS in PHC unite without direct access to a medical laboratory. The RPR-TD was chosen over the standard venereal disease (VDRL) test because of several operational advantages including antigen stability and, possibility to carry out the test without the use of laboratory equipment such as the water bath, microscope or mechanical rotator. The test can be done and treatment can be given at initial contact thereby increasing patient and health care provider compliance. While a tendency towards reduction in fetal and infant mortality attributable to treatment could be demonstrated, there remained a large mortality gradient between the exposed and unexposed that appeared to be related in part to treatment failure, to diagnostic inaccuracy and to the presence of HIV co-infection.